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A  Plea  for  a  Federal  Commission 
on  Tuberculosis 


BY 

LEE  K.  FRANKEL,  Ph.D. 

Sixth  Vice-President  Metropolitan  Life  Insurance  Company 

New  York 


A  Paper  Read  at  the 

Mississippi  Valley  Conference  on  Tuberculosis 

Indianapolis,  September  30,  1915 


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A  Plea  for  a  Federal  Commission 
on  Tuberculosis 


The  interest  of  life  insurance  companies  in  the  prevention 
of  tuberculosis  can  best  be  indicated  by  the  facts  of  their 
mortality  statistics.  In  the  year  1914,  the  Metropolitan  Life 
Insurance  Company  paid  in  its  Industrial  Department  163,339 
claims  on  the  lives  of  113,989  people,  amounting  to  $21,449,401. 
Of  these,  27,928  claims  on  the  lives  of  19,865  people,  amount- 
ing to  $3,949,421,  were  paid  on  individuals  who  died  from 
pulmonary  or  other  forms  of  tuberculosis.  Including  mortuary 
bonuses  the  figure  was  $4,218,139.  It  is  probable  that  the 
experience  of  other  Industrial  life  insurance  companies  is  quite 
similar  to  that  of  the  Metropolitan.  According  to  the  In- 
surance Year  Book  there  were  in  force  at  the  end  of  1914, 
31,134,303  Industrial  insurance  policies,  of  which  13,588,050, 
or  43.6  per  cent,  were  carried  by  the  Metropolitan.  On  this 
basis,  Industrial  insurance  companies,  during  the  year  1914, 
paid  claims  on  the  lives  of  nearly  46,000  working  men  and 
other  members  of  their  families  amounting  to  over  $9,000,000 
for  deaths  due  to  tuberculosis. 

It  will  be  seen  from  the  above  that  it  is  desirable  from  the 
insurance  standpoint  to  reduce  mortality  from  tuberculosis, 
and  if  such  an  ideal  could  ever  be  obtained,  to  eradicate  the 
disease  entirely.  If  the  payment  of  death  claims  could  be 
postponed,  the  ultimate  result  would  be  a  reduction  in  the 
cost  of  insurance.  Possibilities  of  such  postponement  with 
respect  to  tuberculosis  are  large.  Of  the  total  deaths  from 
tuberculosis  in  the  year  1914  in  the  Metropolitan  experience 
70  per  cent,  were  between  ages  15  and  44.  Tuberculosis 
formed  37  per  cent,  of  all  the  deaths  between  these  ages.  If 
the  disease  could  be  eliminated  or  materially  reduced  in  extent 
it  is  probable  that  more  individuals  would  die  from  diseases 
characteristic  of  older  life,  such  as  the  cardio-vascular  diseases. 
The  tuberculosis  problem  from  the  standpoint  of  life  insurance 
companies  is,  as  you  will  see  from  the  above,  primarily  economic 
in    character.     Reduction   in   mortality   from    tuberculosis   or 

1 


reduction  in  the  incidence  of  disease  spells,  in  the  long  run, 
cheaper  insurance. 

The  mortalit}^  experience  of  life  insurance  companies,  if 
it  could  be  assembled,  would  bring  out  many  interesting  facts 
regarding  tuberculosis  which  would  offer  much  food  for  thought. 
I  am  unable  to  offer  you  to-day  any  experience  other  than  the 
one  of  the  Company  with  which  I  am  connected,  but  I  am  of 
the  impression  that  this  experience  would  be  a  counterpart 
of  the  experience  of  the  other  companies.  For  this  reason  it 
can  be  taken  as  a  measure  of  the  conditions  which  exist  among 
the  element  of  the  population  insured  with  the  Industrial 
companies.  The  advantage  of  these  statistics  is  that  they 
represent  definite  classes  of  the  population  by  age-period,  sex, 
race  and  occupation  For  this  reason  the  data  will  probably 
be  as  reliable  as  the  vital  statistics  of  the  Registration  Area 
of  the  United  States,  although  they  are  not  so  extensive  as  to 
numbers. 

I  shall  quote  from  Table  1,  showing  the  decline  in  the 
Metropolitan  Life  Insurance  Company's  white  mortality  from 
seven  principal  causes  of  death  for  the  year  1914  as  com- 
pared with  the  year  1911.  The  statistics  for  tuberculosis  are 
very  interesting.  They  show  that  within  the  short  period  of 
three  years  the  death  rate  from  tuberculosis  in  the  Company's 
experience  dropped  from  208.7  per  hundred  thousand  to  189.6 
per  hundred  thousand,  or  a  reduction  in  the  rate  of  9.1  per 
cent.  These  figures  supplement  those  for  the  Registration 
Area  for  the  years  1901  to  1911,  which  show  a  rate  in  1911, 
83  per  cent,  of  that  in  1901.  All  of  this  indicates  that  the 
campaign  of  education  which  has  been  carried  on  for  over  a 
decade  is  bearing  and  has  borne  fruit.  It  is  fairly  safe  to 
predict  that  the  experience  of  the  next  three  years  will  show 
a  further  reduction  in  the  tuberculosis  death  rate  of  the  country 
and  of  the  life  insurance  companies. 

If  we  analyse  these  figures  according  to  age,  sex,  color, 
occupation  and  locality,  or  compare  them  with  the  decline  in 
death  rates  from  other  diseases,  we  find  several  interesting 
facts  that  are  well  worth  our  careful  attention  and  study. 
While  it  is  true,  as  stated  above,  that  in  our  experience  the 
death  rate  from  tuberculosis  has  declined  9.1  per  cent.,  we 
find,  as  will  be  seen  from  the  table  below,  that  reductions  in 
death  rates  have  been  even  more  marked  in  certain  other 
well-known   diseases.     For   example,    the   reduction   in   three 

2 


years  in  the  death  rate  from  typhoid  fever  was  30.2  per  cent., 
from  acute  infectious  diseases  of  children  19.7  per  cent.,  from 
acute  and  chronic  bronchitis  23.3  per  cent.,  from  all  forms  of 
pneumonia  13  per  cent.,  from  cirrhosis  of  the  liver  17.5  per  cent. 
It  is  possible  that  the  anti-tuberculosis  campaign  may  have 
contributed  to  these  reductions.  To  the  insurance  company 
the  question  naturally  arises:  Why  should  the  reduction  in 
the  death  rate  from  tuberculosis  be  less  than  from  other  diseases 
mentioned?'  Has  the  campaign  for  the  prevention  of  other 
infectious  diseases  been  carried  on  more  effectively  than  the 
campaign  against  tuberculosis?  Are  there  other  underlying 
reasons  and  causes  which  have  brought  about  a  greater  decline 
in  one  disease  than  in  the  other? 


TABLE  1 

NUMBER  AND  PERCENTAGE  OF  DEATHS  FROM  CERTAIN  CAUSES, 

SHOWING  IMPROVEMENT  IN  MORTALITY-WHITE  LIVES 

Metropolitan  Industrial  Premium  Paying  Business,  1911  and  1914 


CAUSE  OF  DEATH 


Typhoid  fever 

Acute  infectious  diseases  of  childhood  (measles, 
scarlet  fever,  whooping  cough,  diphtheria  and 
croup) 

Tuberculosis  (all  forms) 

Acute  and  chronic  bronchitis 

Pneumonia  fall  forms) 

Cirrhosis  of  the  Uver 

External  causes 

Total  above  causes 


1106 


4160 
14274 
892 
7700 
1128 
6963 


.36223 


4.8 
16.3 
1.0 
8.8 
1.3 
8.0 


13.2 


40.7 
189.6 

12.5 
100.8 

16.5 


4243 
13221 
976 
7335 
1142 
6467 


5.3 
16.6 
1.2 
9.2 
1.4 
8.1 


18  9 


50.7 
208.7 

16.3 
115.8 

20.0 

99.9 


.30.2 


19.7 
9.1 
23.3 
13.0 
17.5 
11.1 


41  5 


462.2 


34690 


43.5 


.530  3 


12.8 


A  similar  study  of  the  death  rates  for  colored  lives  insured 
with  the  Metropolitan  brings  out  equally  interesting  data. 
In  this  group,  the  reduction  in  the  death  rate  from  typhoid 
fever  for  the  three  years  studied,  has  been  27.7  per  cent,  as 
compared  with  30.2  per  cent,  for  white  lives.  Acute  infectious 
diseases  of  children  show  a  decline  in  the  death  rate  of  23.2 
per  cent.,  whereas  among  whites  the  reduction  was  onlv  19.7 
per  cent.  Pneumonia  shows  a  reduction  of  14.5  per  cent,  as 
compared  with  13  per  cent,  for  whites.  But  when  we  consider 
tuberculosis,  we  find  a  decline  of  only  2.8  per  cent,  as  compared 
with  9.1  per  cent,  for  white  lives.  The  question  arises:  Why 
should  the  reduction  in  death  rates  for  typhoid  fever,  infectious 
diseases  of  children  and  pneumonia  be  fairly  close  for  these 

3 


two  race  groups  of  our  policy-holders,  and  the  decline  in  the 
death  rate  from  tuberculosis  be  so  disproportionate?  If  the 
living  and  working  conditions  which  bring  about  high  death 
rates  from  tuberculosis  among  negroes  maintain,  why  have 
they  not  exercised  their  influence  on  other  diseases?  Or,  is  it 
possible  that  these  conditions  affect  tuberculosis  only? 

If  we  study  the  tuberculosis  death  rate  in  terms  of  age, 
sex  and  color  classes,  other  interesting  facts  are  at  once  observed 
and  are  shown  in  Table  2.  Comparing  the  death  rates  given 
for  the  two  years  1911  and  1914,  it  is  found  that  while  there 
has  been  a  decline  in  the  death  rate  for  all  ages  for  white  males, 
white  females  and  colored  females,  there  has  been  an  increase 
in  the  death  rate  among  colored  males.  If  we  consider  white 
males  separately,  we  find  there  has  been  a  decline  in  the  death 
rate  at  all  ages,  except  between  ages  1  and  5,  and  ages  45  and  54, 
Similarly,  among  white  females  there  has  been  a  decrease  in 
the  death  rates  in  all  ages  except  between  ages  10  and  14, 
where  there  has  been  an  increase  of  5.1  per  cent.  The  increase 
in  the  death  rate  from  tuberculosis  among  colored  males  at 
all  ages  is  accounted  for  by  the  marked  increases  between 
ages  25  and  54,  the  increase  being  6  per  cent,  between  ages 
25  and  34,  15  per  cent,  between  ages  35  and  44,  and  10.3  per 
cent,  between  ages  45  and  54.  If  we  attempt  to  explain  this 
increase  on  occupational  grounds,  we  are  at  once  confronted 
by  the  fact  that  at  the  same  ages  among  white  males  there 
has  been  a  decrease  between  ages  25  and  44,  whereas  at  ages 
45  to  54  there  has  been  an  increase  in  the  death  rate  of  white 
males  corresponding  almost  with  the  increase  among  colored 
males.  Again,  if  we  study  the  death  rate  among  colored 
females,  we  find  a  decrease  at  all  ages  excepting  ages  15  to  19, 
where  there  has  been  an  increase  of  2.6  per  cent.,  and  at  ages 
45  to  54,  where  there  has  been  an  increase  of  8  per  cent. 

These  peculiar  facts  raise  questions  to  life  insurance  com- 
panies which  are  difficult  to  answer.  It  is  difficult  to  under- 
stand why  white  girls  between  ages  10  and  14  should  show  a 
higher  death  rate  in  1914  than  in  1911,  or  why  there  should 
be  an  increase  in  the  death  rate  among  colored  men  between 
the  ages  25  and  54  (particularly  in  view  of  the  fact  that  the 
death  rate  among  colored  males,  as  is  well  known,  has  always 
been  considerably  higher  than  among  white  males). 

If  the  campaign  for  the  prevention  of  tuberculosis  had  been 
uniform  in  its  effects,  it  would  have  followed  that  a  reduction 

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in  the  death  rate  would  have  been  shown  at  all  ages  for  both 
sexes  and  for  negroes  as  well  as  whites.  The  question  which 
I  propound  is  this:  What  explanation  can  be  offered  for  the 
irregularities  in  the  death  rate  above  indicated? 

Studied  from  the  standpoint  of  occupation,  tuberculosis 
mortality  again  offers  significant  data  as  indicated  in  Table  3. 
Experience  of  the  Metropolitan  shows  that  20.5  per  cent,  of 
the  deaths  of  occupied  white  males,  ages  15  and  over,  are  due 
to  tuberculosis  of  the  lungs,  whereas  35  per  cent,  of  the  deaths 
among  clerks,  bookkeepers,  office  assistants  are  caused  by  this 
disease.  On  the  other  hand,  only  14  per  cent,  of  the  deaths 
among  railway  enginemen  and  trainmen  and  only  5.8  per  cent, 
of  deaths  among  coal  miners  are  caused  by  consumption.  If 
we  remember  that  coal  miners  live  and  work  under  conditions 
which,  presumably,  are  favorable  to  the  development  of  tuber- 
culosis, namely,  in  dark  and  often  badly  ventilated  places,  it 
becomes  difficult  to  reconcile  this  low  mortality  with  our  pre- 
conceived views  on  the  subject. 

If  we  study  this  table  according  to  age  groups,  other  in- 
teresting facts  are  developed.  Among  clerks,  bookkeepers  and 
office  assistants,  35  per  cent,  of  all  deaths  over  15  years  of  age 
are  caused  by  tuberculosis,  and  between  ages  25  and  34,  51.2 
per  cent,  of  the  deaths  are  due  to  this  disease.  Only  21.9 
per  cent,  of  the  deaths  among  painters,  paper-hangers  and 
varnishers,  all  ages  over  15,  are  due  to  tuberculosis,  and  at 
ages  25  to  34  only  42.9  per  cent,  of  the  deaths  are  caused  by 
tuberculosis.  Do  these  figures  mean  that  resistance  among 
painters,  paper-hangers  and  varnishers  is  greater  than  among 
clerks  at  the  younger  ages,  or  are  there  occupational  con- 
ditions which  influence  the  mortality  in  the  clerk  group  more 
than  they  do  those  in  the  painter  group?  If  we  study  the 
age  period  35  to  44  we  find  that  tuberculosis  kills  off  346 
painters  out  of  every  1,000  painters  who  die  at  these  ages,  and 
that  only  334  clerks,  bookkeepers  and  office  assistants  die  from 
tuberculosis  out  of  1,000  deaths  in  this  occupation  group  and 
age  period.  What  do  these  figures  mean?  Is  the  influence  of 
occupation,  particularly  the  influence  of  lead  poisoning  begin- 
ning to  manifest  itself  among  painters  as  they  grow  older  and 
does  a  clerk  who  has  passed  age  25  show  greater  resistance  to 
tuberculosis? 

Studied  from  the  standpoint  of  locality,  more  questions 
arise  which  interest  and  at  the  same  time  mystify  life  insurance 

6 


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companies.  I  could  cite  statistics  from  various  sections  of 
the  United  States  which  would  show  marked  differences  in  the 
death  rates  in  various  cities.     For  example:  our  colored  death 

7 


rate,  all  causes,  is  the  same  in  Cincinnati  as  it  is  in  Louisville. 
On  the  other  hand,  our  death  rate  per  hundred  thousand  from 
tuberculosis  on  colored  lives  is  375.4  in  Louisville  and  479.2  in 
Cincinnati.  I  have  cited  the  above  statistics,  not  with  the 
intention  of  definitely  establishing  any  hypothesis,  but  rather 
to  elucidate  the  thought  which  I  had  in  mind  in  the  presenta- 
tion of  this  paper.  It  is  quite  probable  that  other  statistics 
may  be  quoted,  which  would  negative  any  deductions  drawn 
from  the  data  herein  contained. 

Those  of  you  who  have  been  interested  in  the  tuberculosis 
campaign  will  probably  concede  that  there  has  been  a  change 
of  attitude  in  the  past  few  years  with  respect  to  the  value  of 
the  campaign  and  the  results  obtained.  I  can  recall  how  more 
than  a  decade  ago  we  took  as  the  slogan  for  our  work:  "Tuber- 
culosis is  not  only  curable,  but  preventable."  Based  upon  the 
results  obtained  in  the  cure  of  tuberculosis  we  accepted  as  correct 
the  belief  that  the  conditions  to  effect  a  cure  such  as  fresh  air, 
proper  and  sufficient  food,  proper  living  conditions,  etc.,  were 
necessary  also  to  prevent  tuberculosis.  We  have  accepted 
these  as  fundamentals  in  our  anti-tuberculosis  work.  Any 
anti-tuberculosis  association,  which  has  come  into  existence 
within  the  last  ten  years,  has  spent  its  funds  and  carried  on 
its  campaign  largely  along  these  lines.  Only  recently  have 
we  begun  to  question  whether  our  foundations  are  built  on 
sand  or  on  solid  rock.  Do  we  really  know  the  etiology  of 
tuberculosis?  Are  we  acquainted  with  the  conditions  under 
which  the  tubercle  bacillus  develops  and  thrives?  Is  our 
campaign  against  tuberculosis  the  proper  and  logical  one  that 
will  lead  to  the  final  extinction  of  the  disease?  Do  statistics 
and  other  facts  indicate  that  we  have  made  or  are  making 
headway?  Are  we  convinced  that  our  efforts  to  prevent 
spitting,  to  sterilize  milk,  to  have  working  men  employed  under 
proper  sanitary  and  hygienic  conditions,  to  see  that  families 
are  properly  housed,  are  really  the  lines  along  which  we  ought 
to  work  in  the  future  in  the  hope  that  the  primary  purpose 
of  the  tuberculosis  campaign  may  be  developed? 

I  have  no  wish  to  stand  here  to-day  as  a  critic  of  the  things 
that  have  been  attempted  since  the  anti-tuberculosis  crusade 
was  started,  and  yet  we  must  realize  that,  unless  we  are  willing 
to  examine  our  work  carefully  and  honestly,  critics  may  arise 
from  the  outside  who  may  condemn  our  efforts  in  no  unmeasured 
terms.     I  need  not  recall  to  you  at  this  time  the  fact  that 


there  are  those  who  doubt  whether  the  reduction  in  the  death 
rate  from  tuberculosis  in  the  last  ten  years  can  be  attributed 
to  the  efforts  of  the  anti-tuberculosis  movement.  It  is  even 
claimed  that  similar  reductions  have  taken  place  for  a  number 
of  earlier  decades  and  probably  would  have  taken  place  without 
our  efforts,  in  line  with  the  general  improvement  in  mortality. 
There  are  doubters  who  contend  that  infection  through  sputum, 
except  in  early  childhood,  is  of  rare  occurrence,  and  that  in 
fact  most  of  us  become  infected  during  childhood  and  set  up 
an  immunity  which  protects  us  from  reinfection.  It  seems 
quite  clear  from  investigations  and  autopsies  which  have  been 
made  in  many  places  that  this  theory  has  good  ground  for 
support.  While  it  is  true  that  there  has  been  a  reduction  in 
the  mortality,  we  have  no  data  to  indicate  whether  there  are 
fewer  cases  of  tuberculosis  than  there  were  ten  years  ago. 
Until  we  have  morbidity  statistics  it  will  be  impossible  for  us 
to  say  whether  our  campaign  has  been  at  all  successful  along 
preventive  lines  in  reducing  the  numbers  of  individuals  annually 
afflicted  with  the  disease. 

I  think  it  is  time  for  us  to  pause  and  consider  why  the 
results  which  have  been  obtained  have  not  been  larger.  Even 
admitting  that  there  has  been  a  pronounced  and  gratifying 
reduction  in  the  death  rate,  I  have  indicated  above  by  the 
statistics  submitted  that  there  have  been  even  more  marked 
and  greater  reductions  in  death  rates  of  other  diseases.  Can 
we  consider  these  facts  as  they  are  and  endeavor  with  the 
material  at  hand  to  formulate  to  our  satisfaction  the  reasons 
for  this  difference  so  that  we  may  possibly  elaborate  a  pro- 
gram for  the  future. 

If  I  may  be  permitted  to  express  my  own  views,  I  will  say 
that  the  causes  which  have  most  largely  affected  the  com- 
paratively slight  results  obtained  are  inherent  in  the  disease 
itself.  One  of  the  great  difficulties  in  the  eradication  of  the 
disease  lies  in  the  fact  that  it  is  a  chronic  disease  whose  onset 
is  slow  and  whose  progress  in  most  instances  covers  compara- 
tively long  periods  of  time.  It  is  because  of  this  chronicity  that, 
notwithstanding  all  that  has  been  written  about  phthisiophobia, 
real  fear  and  horror  of  the  disease  have  never  taken  possession 
of  the  great  masses  of  the  people.  We  have  learned  to  accept 
the  affliction  of  tuberculosis  with  a  certain  fatalism.  Much 
of  the  early  belief  in  the  heredity  of  the  disease  still  maintains, 
and,  in  fact,  is  being  accentuated  by  the  most  recent  researches 

9 


which  lead  to  the  beUef  that  heredity  does  play  a  part,  if  not 
in  the  transmission  of  the  disease  at  least  in  its  development. 
I  am  convinced  that  if  tuberculosis  were  an  acute  disease, 
whose  onset  was  short  and  rapid,  whose  course  was  in  most 
instances  fatal  within  a  comparatively  short  time,  we  would 
long  since  have  found  the  means  to  prevent  the  disease,  pre- 
cisely as  we  have  done  with  smallpox,  yellow  fever,  Asiatic 
cholera,  malaria  and  typhoid  fever.  I  am  not  certain  whether 
our  slogan  of  proclaiming  tuberculosis  to  be  curable  has  not 
injured  rather  than  benefited  the  cause.  The  very  hopeful- 
ness of  our  attitude  has  tended  to  weaken  efforts  on  the  part 
of  individuals  and  communities  to  adopt  necessary  prophy- 
lactic measures  and  to  institute  radical  campaigns  of  prevention. 
Is  it  not,  therefore,  necessary  for  us  at  this  time  to  reassemble 
our  facts  and  determine  whether  with  the  information  at  hand 
we  shall  proceed  along  the  lines  which  we  have  laid  down,  or 
whether  it  is  not  necessary  for  us  to  establish  new  criteria  and 
new  bases  for  future  action? 

If  I  may  be  permitted  another  personal  expression  of 
opinion,  I  would  venture  the  suggestion  that  the  weakness  of 
our  campaign  is  due  to  the  fact  that  we  have  accepted  certain 
premises  which  have  not  been  scientifically  and  accurately 
demonstrated.  Statistics  have  shown  us  that  tuberculosis 
seems  to  thrive  best  where  there  are  bad  housing  conditions, 
poor  and  inadequate  food,  overwork,  bad  light  and  bad  venti- 
lation, and  yet  as  a  matter  of  fact  there  are  no  reliable  scientific 
data  to  establish  any  of  these  beliefs.  The  illustration  which 
I  have  given  above  of  the  small  proportion  of  deaths  from 
tuberculosis  among  coal  miners,  who  frequently  work  under 
a  number  of  the  bad  conditions  just  mentioned,  indicates 
rather  clearly  that  most  careful  investigations  are  still  necessary 
to  determine  whether  our  theories  are  correct.  The  peculiar 
variations  which  I  have  shown  in  the  Metropolitan  experience 
with  respect  to  age,  sex,  color  and  locality  all  indicate  that  we 
are  only  at  the  beginning  of  accurate  scientific  investigations 
regarding  the  etiology  of  tuberculosis.  What  is  needed  is 
an  exhaustive,  comprehensive  and  intensive  study  of  the 
many  complicated  and  complex  factors  which  are  involved  in 
the  persistence  of  this  disease. 

If  our  present  methods  are  inadequate,  have  we  any  data 
which  point  the  way  for  the  future?  I  think  the  facts  are  so 
clear  that  he  who  runs  may  read.    If  we  compare  the  typhoid 

10 


death  rate  in  Cincinnati  with  that  of  other  cities  in  the  same 
geographical  area  we  find  marked  differences.  The  typhoid 
fever  death  rate  in  Cincinnati  to-day  is  among  the  lowest  in 
the  United  States.  The  Metropolitan  experience  for  1913-1914 
shows  only  one  colored  and  ten  white  deaths.  The  reason  for 
this  is  obvious.  Ohio  River  water  had  long  been  known  to  be 
the  source  of  infection.  Cincinnati  deliberately  spent  millions 
of  dollars  to  provide  its  citizens  with  a  proper  water  supply. 
The  results  were  immediate  and  conclusive.  If  the  same 
concerted  and  deliberate  action  had  been  taken  with  respect  to 
tuberculosis,  if  the  city  of  Cincinnati  had  been  prepared  to 
expend  equally  large  sums  in  a  campaign  against  tuberculosis 
after  an  intensive  study  of  the  causes  which  produce  it,  it  is 
no  exaggeration  to  say  that  the  tuberculosis  death  rate  per 
hundred  thousand  would  to-day  no  longer  be  expressed  in 
three  figures. 

There  are  other  apt  illustrations  to  show  us  the  course  we 
must  pursue.  At  the  meeting  of  the  American  Public  Health 
Association  held  in  Rochester  a  few  weeks  ago.  Dr.  Gorgas 
detailed  the  campaign  which  had  been  carried  on  in  Cuba 
to  eradicate  yellow  fever.  He  described  the  original  belief 
that  yellow  fever  was  a  dirt  disease,  and  told  of  the  incessant 
campaign  waged  in  every  part  of  Cuba  to  clean  up.  No  effort 
was  spared  to  put  the  island  in  sanitary  condition,  and  yet 
the  campaign  was  a  failure  so  far  as  the  prevention  of  yellow 
fever  was  concerned.  Only  after  the  discovery  of  the  cause 
of  infection,  the  yellow  fever  mosquito  (stegomya  fasciata), 
which,  as  you  know,  was  the  result  of  a  series  of  most  elaborate 
researches  and  studies,  was  the  correct  method  of  preventing 
the  disease  found  and  applied.  It  is  of  importance  to  point 
out  here  some  of  the  things  that  were  done  by  General  Gorgas, 
with  practically  the  power  of  a  Czar  and  with  practically 
unlimited  financial  resources.  Among  other  things,  he  estab- 
lished not  only  a  marine  quarantine,  but  a  land  quarantine 
as  well.  No  individuals  were  allowed  to  enter  what  were 
practically  segregated  cities  cither  from  the  land  or  from  the 
sea  excepting  after  careful  inspection  and  examination,  A 
thoroughly  organized  campaign  to  exterminate  the  mosquito 
was  developed.  The  result  after  fourteen  years,  as  Dr.  Gorgas 
put  it,  is  that  yellow  fever  disappeared  from  the  island. 

Will   you   endeavor  to   visualize   with   me   another  island, 
preferably  smaller  than  Cuba,  in  which  an  attempt  would  be 

11 


made  to  get  at  the  root  of  the  tuberculosis  problem  in  a  manner 
similar  to  the  one  in  which  General  Gorgas  handled  yellow 
fever.  I  can  conceive  of  such  an  island  being  placed  in  charge 
of  a  sanitarian  of  the  Gorgas  type  and  given  almost  autocratic 
power.  He  would  not  lack  necessary  funds  to  carry  on  the  task 
assigned  him.  Such  a  man  with  competent  assistants  would 
carry  out  a  well-defined  policy  of  experimental  research  to 
determine  not  merely  the  medical  and  bacteriological  causes 
which  produce  tuberculosis,  but  would  supplement  such 
research  with  exhaustive  studies  into  the  social  causes  which 
enable  the  disease  to  develop  and  persist.  When  these  had 
been  determined,  our  sanitarian  would  use  the  unlimited 
powers  which  had  been  placed  at  his  disposal  to  see  to  it  that 
there  were  no  infractions  or  violations  of  any  laws,  rules  or 
ordinances  which  he  might  enact  tending  toward  the  elimi- 
nation of  conditions  causing  infection. 

Fantastic  as  the  idea  may  appear  to  us  at  the  present  time 
with  our  limited  vision,  I  can  conceive  that  on  this  mythical 
island  every  resident,  irrespective  of  his  state  of  health  would 
be  subjected  to  a  rigid  medical  examination.  A  careful  record 
would  be  kept  of  his  social  and  medical  history.  He  would 
be  re-examined  periodically  to  determine  whether  any  changes 
had  taken  place  in  his  physical  condition.  If  his  family  history 
showed  hereditary  tendencies  to  tuberculosis,  such  examina- 
tions would  be  conducted  at  more  frequent  intervals.  Each 
resident  of  this  island  would  be  studied  with  respect  to  age, 
sex  and  occupation.  The  conditions  under  which  he  lived  and 
worked  would  be  carefully  recorded.  The  influences  which 
these  conditions  might  have  upon  his  state  of  health  would 
be  determined.  On  this  ideal  island  no  one  would  be  per- 
mitted to  enter  who  could  not  conform  to  the  standards  set 
up  by  a  board  of  medical  experts  and  students  of  social  problems. 
A  land  and  water  quarantine,  similar  to  the  one  established  by 
General  Gorgas  in  Cuba,  would  be  an  accepted  fact  on  this 
ideal  island. 

These  things  would,  however,  be  only  preliminaries.  Our 
sanitarian  would  undoubtedly  provide  for  a  careful  inspection 
of  all  the  food  supplies  used  by  the  people  who  lived  there. 
Milk  inspection  would  not  be  a  perfunctory  act.  The  pre- 
vention of  spitting  would  be  more  than  an  unenforced  statute. 
Inventors  would  be  asked  to  design  practicable  receptacles 
for  sputum,  and  the  furnishing  of  these  in  sufhcient  number  and 

12 


in  convenient  places  would  be  as  much  a  duty  of  the  authori- 
ties as  a  good  water  supply,  sewers  or  comfort  stations. 

Nor  would  preventive  measures  end  here.  Every  case  of 
tuberculosis  that  was  found  would  be  carefully  studied  to 
determine  the  conditions  under  which  it  arose.  Sanatorium 
treatment  would  be  given  to  the  early  cases.  The  people 
would  be  educated  as  a  matter  of  public  and  personal  duty,  to 
bring  to  the  notice  of  the  authorities  any  symptoms  which 
might  indicate  the  beginnings  of  a  tuberculous  infection.  Ade- 
quate hospital  facilities  w^ould  be  provided  for  advanced  cases. 
For  those  whose  condition  was  hopeless  and  for  whom  segre- 
gation was  required,  opportunity  would  be  given  to  pass  their 
remaining  days  in  modern  institutions  with  attractive  surround- 
ings, in  which  every  consideration  would  be  given  to  their  care 
and  comfort. 

It  is  only  necessary  to  add  that  in  this  mythical  island 
every  phase  of  modern  public,  personal  and  industrial  hygiene 
would  be  developed.  In  particular  the  influence  of  occupation 
on  health  and  as  a  factor  in  producing  tuberculosis  would 
receive  the  closest  attention.  In  time  the  authorities  would 
probably  ascertain,  by  careful  and  accurate  experiment,  what 
influence  housing,  air  and  ventilation  have  in  the  spread  of 
tuberculosis,  and  whether  race,  wages,  nationality,  sex,  age, 
occupation,  alcohol,  venereal  disease,  and  heredity  play  im- 
portant or  negligible  parts. 

I  think  I  have  said  enough  to  indicate  to  you  the  thought 
I  have  in  mind,  namely,  that  we  shall  not  begin  to  handle 
the  tuberculosis  problem  effectively  until  we  institute  methods 
similar  to  those  that  were  employed  in  Cuba  and  in  the  Philli- 
pines.  These  methods  involve  (1)  accurate  and  painstaking 
scientific  research  along  both  medical  and  social  lines,  (2)  the 
application  of  the  results  of  such  research  to  isolated  and  if 
necessary  segregated  groups  of  individuals  who  may  be  kept 
under  constant  observation,  (3)  authority  to  enfore  regulation, 
and  (4)  adequate  finances.  The  science  of  medicine  has 
reached  its  present  highly  developed  state  by  reason  of 
years  of  endless  and  painstaking  research.  The  profession 
of  chemistry  would  still  be  in  the  unenlightened  period  of 
alchemy  had  it  not  been  for  the  laboratories  devoted  to  scientific 
investigation.  Other  professions  and  arts  tell  the  same  story. 
Medical  research  has  proven  beyond  pcradventure  that  tuber- 
culosis is  a  specific  infection  of  the  tubercle  bacillus.     How  it 

13 


thrives  and  develops  is  in  part  known  and  in  part  assumed. 
If  the  disease  is  ever  to  be  eradicated,  we  must  definitely  know 
facts  and  dispense  with  assumptions.  That  this  has  been  done 
with  other  diseases  is  too  well  known  to  require  further  com- 
ment. Precisely  the  same  course  as  has  been  pursued  with 
these  diseases  must  be  followed  with  tuberculosis. 

The  question  may  be  asked,  "But  what  of  the  cost?"  I 
reply,  that  we  may  not  consider  cost  with  respect  to  a  disease 
which  to-day  causes  more  deaths  than  any  other.  As  it  is, 
according  to  the  statement  of  the  National  Association  for 
the  Study  and  Prevention  of  Tuberculosis,  there  was  spent 
last  year  over  $20,000,000  in  the  campaign  against  tuberculosis 
in  the  United  States.  This  included  the  amount  spent  for 
institutional  care  and  treatment.  In  fact,  over  $18,000,000 
was  spent  for  these  purposes,  largely  curative  in  nature.  Less 
than  $2,000,000  was  spent  in  the  entire  preventive  campaign, 
including  so  far  as  is  known  all  educational  movements  and 
all  research  work.  This  is  a  paltry  sum  when  the  extent  of 
the  disease  is  considered.  I  have  no  doubt  that  if  we  could 
spend  $20,000,000  in  a  determined,  enlightened  and  compre- 
hensive plan,  such  as  I  have  outlined  above,  we  could  look 
forward  with  confidence  in  the  next  decade  to  seeing  as  marked 
a  reduction  in  the  mortality  of  tuberculosis  as  we  have  seen  in 
smallpox,  yellow  fever,  etc. 

You  will  ask,  "Is  not  this  work  for  the  great  insurance 
companies  of  the  United  States?"  My  reply  would  be,  "Yes, 
if  money  were  the  only  need."  I  can  conceive  of  no  better 
purpose  to  use  insurance  surplus,  and,  if  necessary,  even  divi- 
dends, than  for  the  eradication  of  tuberculosis.  Money, 
however,  is  only  one  great  requisite;  the  other  is  authority. 
An  experiment  such  as  I  have  suggested  will  not  come  within 
the  scope  of  private  enterprise.  It  will  be  distinctly  a  function 
of  the  Federal  Government.  Only  the  latter  would  have  the 
sovereign  power,  not  only  to  inaugurate  such  a  campaign,  but 
to  enforce  the  social  and  medical  conditions  under  which  such 
an  experiment  should  be  made. 

In  conclusion,  let  me  suggest  for  your  consideration  the 
adoption  of  a  resolution  calling  upon  the  Congress  of  the 
United  States  to  authorize  the  President  to  appoint  a  Federal 
Commission  on  Tuberculosis  composed  of  eminent  specialists  in 
the  medical,  economic  and  social  phases  of  the  subject.  vSuch 
a  commission  would  have  to  be  vested  with  sufficient  power 

14 


and  authority  and  be  given  ample  financial  support  to  make 
an  intensive  investigation  into  the  etiology  of  tuberculosis.  I 
am  confident  that  the  report  of  such  a  commission  would  show 
definitely  and  unmistakably  the  path  along  %vhich  the  future 
campaign  against  tuberculosis  must  proceed,  if  we  are  ever 
to  eradicate  the  disease. 


[Since  the  presentation  of  this  paper,  the  recommendation 
contained  in  the  last  paragraph  has  been  adopted  by  resolution  of 
the  Mississippi  Valley  Tuberculosis  Conference,  the  South  Atlantic 
Tuberculosis  Conference,  the  New  England  Tuberculosis  Confer- 
ence and  the  North  Atlantic  Tuberctilosis  Conference.] 


15 


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